“Is it a vision problem?”

Does this child have a visually-based problem?

Our children present with a vast array of problems affecting their development and academics. Sensory problems, trauma, autism, behavior, ADHD and the list goes on. Our children get assessed by OTs, and PTs, neurologists, neuropsychologists, and pediatricians. But did they have an eye-exam? A complete eye exam? Only 40% of children have had their eyes examined by an eye doctor. (1) That leaves all of those children potentially walking around with vision problems affecting their academic and developmental development. Meanwhile, we attempt to teach them catch a ball or write the alphabet or button a button.

“Does he need an eye exam?”

YES!!! Every child, regardless of academic performance or other diagnosis, needs a complete eye exam with a binocular vision assessment and cycloplegic dilation, even if the child has never complained about their vision.  Many times, when a child is assessed with the Convergence Insufficiency Symptom Survey, they learn that they are not supposed to see “words moving” on the page or see double when they read. They had symptoms and were not even aware. Most children with ocular motor or near vision problems will read letters on a chart without difficulty. 20/20 means only that each eye has good acuity. It does not tell us how well the eyes are working together or how hard the eyes are working to make a 20/20 acuity. Only a complete eye exam with binocular assessment and cycloplegic dilation can give the whole picture.

“Is this is visually-based problem?”

There are many signs a child is having a visual-based problem.

  • Eye rubbing
  • unexplained headaches
  • poor handwriting
  • poor reading skills that do not improve with tutoring
  • head turning or tilting when reading
  • closing one eye while reading
  • poor visual motor integration that does not improve practice
  • poor balance or motion sensitivity
  • Diagnosed ADHD that does not respond to medication
  • unable to catch a ball
  • letter reversals
  • visual perceptual problems
  • spacing and size problems during handwriting tasks
  • fine motor delays
  • poor depth perception

These problems maybe mis-diagnosed as things like dyslexia or ADHD and even be treated as such without success for many years.

“Who do I send them to, to make sure they a complete eye exam?”

A good place to start is College of Optometrists in Visual Development. These doctor specialize in the assessment and treatment of eye movement disorders and near vision focusing problems that could be affecting academic performance. You can your local COVD doctor with the search tool on the site. One might also look for an optometrist that specializes in pediatrics or binocular vision.

When an appointment is made, be specific about symptoms and ask for a “binocular vision assessment”.

Every child

Every child needs a complete eye exam. Parents may have many reasons to not get this dome, but you cannot teach a child read or write, or catch a ball that cannot see.

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1.Children’s Vision Screening and Intervention. (n.d.). Retrieved from https://nationalcenter.preventblindness.org/childrens-vision-screening-and-intervention

Autism and Vision

Autism and Sight

There has been several recently published articles on autism with some dysfunctions being found at a higher rate than in the neuro-typical population. One study, published in January 2017, found consistently that children with autism reacted slower to changes in light (pupillary light reflex). The pupillary light reflex was slower when lighting changed and, in darkness, the pupil measured smaller than controls.(1)

A second study, published in 2018, found a higher rate of accommodative problems (17.4% for ASD, vs 4.9% control) for children diagnosed with autism. While there was no substantial difference in the rate of refractive error, this higher rate of accommodative problems makes a complete eye exam with assessment of near vision acuity more important.(2)

A review of evidence found several contradictory studies concerning the prevalence of eye movement defects associated with autism, though most agree that saccades inaccuracy as well as difficulties in tracking are common in ASD. These movement problems, coupled with other fine and gross motor deficits found in autism suggests a cerebellar problem.(3)

Autism and Vision

Difficulties with the integration of visual information is found in several studies. All of these studies point to a lack of integration between the parvocellular and magnocellular tract and reduced communication between these tracts.(3)

Studies found differences in VEPs (visually evoked potentials) studies in the activity of the magnocellular tract compared to neuro typical children. The difference was, most notably, a slower recovery period for the magnocellular tract and therefore, decreased integration of the information. Functionally, this may help explain the visual spatial problems frequently seen in ASD diagnosed children. (4, 5)

Lateral gazing’ behavior was also found in some children with ASD as they attempted to use peripheral vision to reduced central visual pathway input. (3) This behavior is also suggestive of magnocellular tract deficits.

Integration Deficits

A common thread through many of these studies is a decreased integration of visual information and motor pathways and the cerebellum. (6) This lack of integration could help explain the ocular motor and saccade problems, as well as increased incidence of gait problems and toe walking (7,8) and visual motor integration problems found in children with ASD. A study also showed that people with ASD do not make good use of visual information to correct posture (9). Addressing this lack of integration could be helpful making functional progress with children on the spectrum.

Summary

A complete binocular vision exam with cycloplegic dilation is very important for every child with autism (and neuro typical children too) given the potential for a higher rate of accommodative and ocular motor problems and fine motor, reading and handwriting problems.

Given the evidence of integration problems, activities for children with ASD should be “top down” type activities that require the integration of movement and vision.

Much of this research is very recent and found some changes from previous research. Many of the studies suggested these differences in results were related to redefining autism with the release of DSM-5 eliminating Aspergers and pervasive developmental disorder and grouping these into the current terminology of autism spectrum disorder. The inclusion of these subjects in studies have helped improve the understanding of vision and autism. Many of the studies also sited small samples as potential limitations.

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(1)Anketell, P. M., Saunders, K. J., Gallagher, S. M., Bailey, C., & Little, J. A. (2018, March). Accommodative Function in Individuals with Autism Spectrum Disorder. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/29424829

(2)DiCriscio, A. S., & Troiani, V. (2017, July 25). Pupil adaptation corresponds to quantitative measures of autism traits in children. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/28743966

(3)Bakroon, A., & Lakshminarayanan, V. (2016, July). Visual function in autism spectrum disorders: a critical review. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/27161596

(4)Jackson, B. L., Blackwood, E. M., Blum, J., Carruthers, S. P., Nemorin, S., Pryor, B. A., . . . Crewther, D. P. (2013, June 18). Magno- and Parvocellular Contrast Responses in Varying Degrees of Autistic Trait. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/23824955

(5)Sutherland, A., & Crewther, D. P. (2010, July). Magnocellular visual evoked potential delay with high autism spectrum quotient yields a neural mechanism for altered perception. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/20513659

(6)Miller, M., Chukoskie, L., Zinni, M., Townsend, J., & Trauner, D. (2014, August 01). Dyspraxia, motor function and visual-motor integration in autism. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/24742861

(7)Accardo, P. J., & Barrow, W. (2015, April). Toe walking in autism: further observations. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/24563477

(8)Kindregan, D., Gallagher, L., & Gormley, J. (n.d.). Gait deviations in children with autism spectrum disorders: a review. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/25922766

(9)Morris, S. L., Foster, C. J., Parsons, R., Falkmer, M., Falkmer, T., & Rosalie, S. M. (2015, October 29). Differences in the use of vision and proprioception for postural control in autism spectrum disorder. Retrieved March 05, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/26314635

Letter Reversals

Letter reversals are frequently an area of concern for parents as their child begins to learn writing and reading. Reversals are often viewed as a sign of dyslexia and are surrounded by myth. Here are the facts on letter reversals

  • Letter reversals are common and appropriate until a child reaches 7 or 8 years old (second grade).
  • After the age of 7-8, the children who continue to have reversals are the children that are having difficulty with reading(1)
  • Learning letters is the first time a child learns that an item becomes a different thing based on the way it is facing. A cup from seen from one side or the other is still a cup but a “b” seen the other way (“d”) is not the same thing.
  • Visual spatial and left/right body awareness correlated with children having letter reversal problems suggesting that addressing left/right awareness would improve letter reversals (2)
  • Working memory deficits, also found in dyslexia, were found in children with letter reversals, so addressing working memory may improve letter reversals. (3)
  • Children with ADHD tend to have more reversals, possibly related to difficulty in an inability to to suppress the more natural left-right flow of making most letters.

Treatment Ideas

Having the child the pull letters from a bag and identify the letters without looking at them has been a great activity (suggested by Dr. Charles Boulet) and correlated well with children having difficulty with this task that have reversal problems.

Dr. Kenneth Lane OD, FCOVD’s book , Developing Ocular Motor and Visual Perceptual Skills: An Activity Workbook, has an excellent discussion of letter reversals as well as treatment techniques. Presenting p-q-d-b chart and having the child touch “p” and “b”  with right and q and d with the left has proven to be very challenging. This activity include a component of eye0hand cooridnation and saccade accuracy that will further improve binocular vision and saccade accuracy.

The Optomteric Extension Program offers Recognition of Reversals Workbook, also by Dr, Lane (a great bookstore!!). This workbook has more activities for reversals and its only $20.

Calm the panic!!

In a few cases, letter reversals after the age of 7-8 can indicate dyslexia, but there are many other reasons a child may have reversals.

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References

  1. Terepocki, M., Kruk, R. S., & Willows, D. M. (n.d.). The incidence and nature of letter orientation errors in reading disability. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/15493319
  2. McMonnies, C. W. (1992, October). Visuo-spatial discrimination and mirror image letter reversals in reading. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/1430744
  3. Brooks, A. D., Berninger, V. W., & Abbott, R. D. (n.d.). Letter naming and letter writing reversals in children with dyslexia: momentary inefficiency in the phonological and orthographic loops of working memory. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/21978009
  4. Levy, F., & Young, D. (n.d.). Letter Reversals, Default Mode, and Childhood ADHD. Retrieved October 04, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/26794673

Equipment for Vision Rehabilitation

“What tools do I need to perform basic vision rehab interventions in my clinic?”

The first thing one needs is information. Understanding and Managing Vision Deficits-A Guide for Occupational Therapists would be a wise investment. Dr. Scheiman’s book explains assessing and treating basic binocular vision defects making the subject approachable for therapists. He also teaches a course by the same name that would be a good start.

Vyne Education also offers a course Vision Rehabilitation for Pediatrics-Seeing the Whole the Picture, taught by this author also introduces basic assessment and treating of eye movement disorders.

The Convergence Insufficiency Treatment Trial Manual’s Chapter 8 explains the in-clinic activities used in the CITT and would also be a worth while read.

You will need an optometrist

This may be the hardest thing to find. While the complete binocular vision assessment is the standard of care, frequently this assessment is neglected. Find the optometrist in your community that consistently performs these assessments and you will most likely find a partner. COVD and NORA doctors may be most receptive to working with a physical or occupational therapist that is training in binocular vision disorders.

The optometrist diagnosis is as important as the diagnosis a therapist would get before starting rehab on a shoulder. While we can perform basic testing on a shoulder, some results would indicate further assessment by the orthopedist. Same rules would apply concerning eye movements except that even poor tracking could be caused by a lack of visual acuity requiring glasses (or more accurate glasses).  Always insist that a child have a current eye exam before working on eye movement or even skills like visual motor integration or visual perception. Performance of these tasks requires best corrected visual acuity.

What about Equipment?

The Worth 4 dot   would be a wise first investment. With models starting at about $20, it it also very cost effective and gives great first clues to a eye movement problem.

Marsden Balls offer an easy to use moving target that requires good fixation to read letters. The handy therapist could probably make one on their own.

The Hart Chart is simple way to strengthen accommodation. Do it on a balance board and add in the challenge of balance.

The brock string is a must and its cousin the barrel card can be used to strengthen convergence.  Have the patient make their own brock string becomes a great fine motor activity too.

The Developmental Eye Movement Test is quick to give assessment that gives good data to reading ability and accuracy.

 

Prism and Lenses

The rules governing the use of prism and lenses vary greatly from state to state with the interpretation of the rules varying. Because of this, the author has chosen not to openly recommend these tools. They would generally require being under the supervision of an optometrist or ophthalmologist for there use and purchase.  They also require training to understand the appropriate therapeutic use of these tools.

Be a therapist!

The near-far axis is generally referred to as the Z-axis. When we turn our midline crossing tasks into the Z axis, we are now working the near far visual system.  Check out a previous post here. Be creative and have fun.

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Visual Motor Integration

Visual Motor Integration and Eye Movements

Visual motor integration is the use of visual information to make a motor plan. These “motor plans” include things like balance, walking in a straight line, handwriting and solving puzzles like mazes and parquetry patterns.

In the earliest days of baby’s life, they see an item across the room. A parent, a toy or a favorite snack can ignite a spark to move. This is a developmentally early example of vision facilitating a motor plan. Without vision, children tend to not explore their environment and consequently show decreased gross motor skills. As children learn to write, visual motor integration plays an important part as the child sees the letter then copies the letter, a fine motor action.

Visual Motor Integration Problems

The visual motor process starts with vision. The child must see the letters accurately in order to copy them accurately. The child then must have adequate strength and coordination to execute the task. Errors in visual motor integration can be related to difficulty with the visual input or motor output of the equation. Error of the motor part tend to be quickly identified as perhaps weak 3 point pinch during hand writing or weak leg muscles while walking a balance beam. But what about the visual input? What if this child has poor eye teaming or reduced vision?

Putting the Visual in Visual Motor

Imagine someone attempting to identify a coin by only using their sense of touch. Only there is glove on their hand. This would be very difficult and the person most likely be incorrect. Does this person have a problem processing tactile information? Of course not! They have not gathered accurate information and therefore will not process to the correct result.

The same thing happens when a child with vision problems as visual motor integration is tested. The child always has reduced visual motor integration because they are not processing accurate visual information.

Visual Motor Assessment and Treatment

The most consistent functional problem seen in children with eye teaming problems is below age appropriate visual motor integration. There are several good tools for assessing visual motor integration including the Test of Visual Motor Skills , Full Range Test of Visual Motor Skills, and Beery Visual Motor Integration test. These all are standardized test and are part of any good occupational therapists assessment.

Children with visual motor integration problems will have reduced balance and difficulty with handwriting and copying from the board. They have difficulty with visual puzzles and finding the visual differences in shapes and drawing. Treatment of the deficits will be very difficult if the child is having eye teaming or other vision problems.

Here are some great sources for visual motor activities:

Tools to Grow     Your Therapy Source    Eye Can Learn

There are some iPad Apps too!!

My Mosaic has kids make pictures moving colored dots.

The Matrix Games has several games for putting shapes together.

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Dyslexia and Vision Rehabilitation

Dyslexia and Vision Therapy

Dyslexia is word frequently tossed about when children have problems reading or learning. Commons complaints that lead to the use of the word include letter reversals, poor reading comprehension and decreased reading fluency. These symptoms are also recognized as possible vision related problems cause by poor eye movement accuracy.

Is dyslexia a vision problem or a language problem?

Attempting to define dyslexia can be confusing. The origin of the word is vague: “dys” meaning difficulty with and “lexia”  meaning reading lends itself to broad interpretation.  The best definition for dyslexia, from the International Dyslexia Association says:

“Dyslexia is a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge.”

The research shows that the root cause of dyslexia is phonological processing, or how the brain processes sounds in language. Additionally, the prevalence of dyslexia is estimated to be between 5-20% of the population, according to the National Institute of Health: http://www.ninds.nih.gov/disorders/dyslexia/dyslexia.htm. *

Reading is a complex process involving language, speech, memory and other processes, but all of these processes assume that the collection of the information to be processed is accurate, ie that the eyes work correctly and move accurately. We do know that poor eye movements lead to poor processing skills because the data to be processed was not collected accurately.

Does vision therapy treat dyslexia?

This is also a very interesting question. In our vision rehab practice, we frequently get children referred to us that have common symptoms of dyslexia and visual processing difficulties like reversals and poor reading skills. Following the interventions, the children have reduced symptoms and most have improved reading fluency.

Some of patients do continue to have problems in reading although they show improved eye movements. At this point, we may further assess the patient using a dyslexia screening tool that can identify specific errors related to the processing parts of reading such as the decoding and encoding of words. When results indicate, we refer those children to specialists like our friends at Read-Write Learning Center at  that specialize in the treatment of dyslexia.

 

Does vision therapy treat dyslexia????

NO. Vision therapy cannot treat dyslexia. But it does improve the accuracy of eye movements eliminating many of the symptoms generally associated with dyslexia. With these eye movement problems gone, an accurate assessment of the visual processing skills and reading fluency is now possible, allowing for an accurate diagnosis of a visual processing or other reading and learning problems.

Here is a video case study describing the process.


*Special thanks to Hunter Oswalt, Director of the Read-Write Learning Center for her input on editing this post.

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